HIV care using differentiated service delivery during the COVID‐19 pandemic: a nationwide cohort study in the US Department of Veterans Affairs

Abstract

IntroductionThe Department of Veterans Affairs (VA) is the largest provider of HIV care in the United States. Changes in healthcare delivery became necessary with the COVID‐19 pandemic. We compared HIV healthcare delivery during the first year of the COVID‐19 pandemic to a prior similar calendar period.MethodsWe included 27,674 people with HIV (PWH) enrolled in the Veterans Aging Cohort Study prior to 1 March 2019, with ≥1 healthcare encounter from 1 March 2019 to 29 February 2020 (2019) and/or 1 March 2020 to 28 February 2021 (2020). We counted monthly general medicine/infectious disease (GM/ID) clinic visits and HIV‐1 RNA viral load (VL) tests. We determined the percentage with ≥1 clinic visit (in‐person vs. telephone/video [virtual]) and ≥1 VL test (detectable vs. suppressed) for 2019 and 2020. Using pharmacy records, we summarized antiretroviral (ARV) medication refill length (<90 vs. ≥90 days) and monthly ARV coverage.ResultsMost patients had ≥1 GM/ID visit in 2019 (96%) and 2020 (95%). For 2019, 27% of visits were virtual compared to 64% in 2020. In 2019, 82% had VL measured compared to 74% in 2020. Of those with VL measured, 92% and 91% had suppressed VL in 2019 and 2020. ARV refills for ≥90 days increased from 39% in 2019 to 51% in 2020. ARV coverage was similar for all months of 2019 and 2020 ranging from 76% to 80% except for March 2019 (72%). Women were less likely than men to be on ARVs or to have a VL test in both years.ConclusionsDuring the COVID‐19 pandemic, the VA increased the use of virtual visits and longer ARV refills, while maintaining a high percentage of patients with suppressed VL among those with VL measured. Despite decreased in‐person services during the pandemic, access to ARVs was not disrupted. More follow‐up time is needed to determine whether overall health was impacted by the use of differentiated service delivery and to evaluate whether a long‐term shift to increased virtual healthcare could be beneficial, particularly for PWH in rural areas or with transportation barriers. Programmes to increase ARV use and VL testing for women are needed.

Impact of the COVID-19 Pandemic on HIV Healthcare Service Engagement, Treatment Adherence, and Viral Suppression in the United States: A Systematic Literature Review

“…Included studies primarily used convenience sampling and recruited participants from various sources. Several studies used survey responses or other data (e.g., from electronic health records, interviews) from participants who were previously or currently enrolled in clinical trials or other study cohorts or interventions (n = 12) [ 15 – 26 ] or who were existing HIV clinic patients (n = 7) [ 27 – 33 ]. Three studies recruited participants using social media [ 34 – 36 ], one study used participants who completed an separate online survey that linked to a COVID-19 survey [ 37 ], and one study recruited participants using mailing lists [ 38 ].…”

“…Fifteen studies looked at the impacts of the pandemic within specific communities living with HIV, including those who identified as Black or LatinX [ 16 , 18 ], identified as a member of the LGBTQ community or MSM [ 23 , 34 , 37 ], identified as Black MSM [ 26 , 35 ], were of older age [ 19 , 38 ], were economically disadvantaged [ 22 , 24 , 28 ], or those who reported substance use [ 21 , 25 , 30 ]. Of the other nine studies that reported participant data (e.g., excluding the two studies that used data provided by Ryan White clinics), seven included varying levels of representation across genders, sexual orientations, races, ethnicities, and other demographic factors [ 15 , 17 , 20 , 29 , 31 , 32 , 36 ]. Two did not provide a demographic overview of the study sample [ 27 , 33 ].…”

“…Telehealth, along with the use of other technologies, helped to ensure continued access to HIV services during the pandemic. There were increases in the number of clinics that offered telemedicine services and the percentage of appointments conducted via telemedicine, when comparing time periods before the pandemic to those during the pandemic [ 9 , 15 , 20 , 27 ]. For example, one San Francisco HIV clinic conducted 86.9% of all appointments by telehealth from March to June 2020, compared to 5.3% from October 2019 to March 2020 [ 27 ].…”

“…Some of the reported reasons for missing ART doses in the literature included forgetting to take doses [ 38 ], disruptions in regular routines [ 23 ], and inability to get a prescription or get to a pharmacy [ 18 , 25 , 37 ]. Studies that assessed ART adherence or coverage identified only small decreases when comparing time periods during the pandemic to before the pandemic [ 15 , 18 , 37 ]. One study reported increased adherence to ART due to heightened fears of participant’s increased risk of COVID-19-related morbidity and mortality as a PWH [ 18 ].…”

The Management of HIV Care Services in Central and Eastern Europe: Data from the Euroguidelines in Central and Eastern Europe Network Group

“…This situation causes difficulties in providing health care to patients in this population. So far, there has been no evidence of major disruption in the continuum of HIV care, which may contribute to a change in the services adapting to the new COVID-19 pandemic situation [12].…”